Professional Referral to be completed by a professional wishing to refer a carer. Professional Referral Form to be completed by a Professional wishing to refer an Adult Carer "*" indicates required fields Step 1 of 4 - Professional Referrer 25% Barnet Carers is a leading charity offering advice, information, emotional and practical support for all informal carers who live or work in the London Borough of Barnet.Please complete the questions below Barnet Carers Referral Process All referrals are sent to our Carers Services Team. We aim to follow-up the referral within 3 working days. Once we have contacted the carer, someone from our Adult Carers Team will email you with a progress update. At busy times, these planned times may be extended. Importance in acquiring Carer's Consent It is important to receive the consent of the named carer. We require the confirmation that the consent of the carer has been given as part of this referral in order to proceed in making contact on completed submission.Has the person you are referring given consent for this referral?* Please tick this box to indicate that consent has been givenName of Professional* First Last Organisation/Sector You Represent*-Please select from options-Age UK BarnetBarnet CABBarnet MencapMiddlesex Association for the BlindOther VCS OrganisationsLBB ASC Social WorkerPractitionersSocial Care DirectSocial PrescribingChildren and Family Services TeamsGP/HospitalsSchools/EducationOtherIf Other, please state the name of your organisation* Referral to Barnet Young Carers Should you be wishing to refer a young carer, our referral form for the young carers service can be accessed by clicking Barnet Young Carers Professional Referral.Job Title of Professional* Contact No. of Professional*Email of Professional* Address of Professional* Street Address Address Line 2 City Postcode How did you hear about us?*-Please select from options-WebsiteColleagueProfessional ForumLeafletOtherIf Other, please state* Name of Carer* First Last Gender of Carer*-Please select from options-MaleFemaleTransgenderNon-binaryPrefer not to sayIs the Carer's Date of Birth known to you? Yes No Carer's Date of Birth* DD slash MM slash YYYY Carer's Preferred Contact No:*Carer's Secondary Contact No:Carer's Email Please enter the postcode below and click on the Lookup Postcode button Carer's Address City Postcode Please select services that the carer would be interested in accessing via Barnet Carers (select as many that apply)* Carers Needs Assessment and Support Plan General information and advice Legal Advice Form-checking (for benefits forms) Training Employability Support Carers Essentials Grant Emergency Card Scheme Counselling Health and Wellbeing Services (i.e. exercise classes, peer-support groups, social events) Barnet Leisure Pass HiddenMain Area of Need [Age UK]-Please select from options-DementiaFrailtyLong-term conditionHiddenMain Area of Need [Barnet Mencap]-Please select from options-First ChoiceSecond ChoiceThird ChoiceHiddenMain Area of Need [Inclusion Barnet]-Please select from options-First ChoiceSecond ChoiceThird ChoiceHiddenMain Area of Need [Mind]-Please select from options-First ChoiceSecond ChoiceThird ChoiceHiddenOther Area of Support-Please select from options-First ChoiceSecond ChoiceThird ChoiceIs the carer affected by any medical or health condition?* Yes No Not aware of If Yes, what condition is the carer affected by?*-Please select from options-Autistic Spectrum Disorder (ASD)Learning DisabilityCancerDementiaMental Health IssuePhysical DisabilityDrug/Alcohol DependencyFrail Through AgingOtherPlease give additional details on diagnosisWhat is the relationship between the carer and the person being cared for?*-Please select from options-BrotherDaughterFatherFriendGrandchildGrandparentHusbandMotherNeighbourParentPartnerSisterSonStep ChildStep ParentWifeOther relativeIf Other, please state* Who does the carer care for?-Please select from options-Person(s) over the age of 18Person(s) under the age of 18BothHow many people under the age of 18 does the carer care for?*-Please select from options-OneTwoThreeFourPlease Note Adults caring for a person under 18 are not eligible for a statutory carer needs assessment. However, they are equally entitled to being registered with Barnet Carers and access its services and support.Is the carer caring for more than one person over the age of 18? Yes No How many people do they care for?-Please select from options-OneTwoThreeName of Person Being Cared For First Last Person Being Cared For's Condition-Please select from options-Autistic Spectrum Disorder (ASD)Learning DisabilityCancerDementiaMental Health IssuePhysical DisabilityDrug/Alcohol DependencyFrail Through AgingOtherPlease give additional details on diagnosisIs the Peron Being Cared For's Date of Birth known to you? Yes No Person Being Cared For's Date of Birth* DD slash MM slash YYYY Does the carer live with the Person Being Cared For?* Yes No Please enter the postcode below and click on the Lookup Postcode button Person Being Cared For's Address City Postcode Name of Person Being Cared For #2 First Last Person Being Cared For #2's Condition-Please select from options-Autistic Spectrum Disorder (ASD)Learning DisabilityCancerDementiaMental Health IssuePhysical DisabilityDrug/Alcohol DependencyFrail Through AgingOtherPlease give additional details on diagnosisIs the Peron Being Cared For #2's Date of Birth known to you? Yes No Person Being Cared For #2's Date of Birth* DD slash MM slash YYYY Does the carer live with the Person Being Cared For #2?* Yes No Please enter the postcode below and click on the Lookup Postcode button Person Being Cared For #2's Address City Postcode Name of Person Being Cared For #3 First Last Person Being Cared For #3's Condition-Please select from options-Autistic Spectrum Disorder (ASD)Learning DisabilityCancerDementiaMental Health IssuePhysical DisabilityDrug/Alcohol DependencyFrail Through AgingOtherPlease give additional details on diagnosisIs the Peron Being Cared For #3's Date of Birth known to you? Yes No Person Being Cared For #3's Date of Birth* DD slash MM slash YYYY Does the carer live with the Person Being Cared For #3?* Yes No Please enter the postcode below and click on the Lookup Postcode button Person Being Cared For #3's Address City Postcode How long have you or your organisation been supporting the carer?*-Please select from options-Less than 6 months7-18 monthsOver 18 monthsPlease give details of the support provided that may help us gain a better understanding of the carer's situation* Is the carer being supported by friends or other family members? Yes No Do they wish to be referred to Barnet Carers' Adult Carers Service?* Yes No If Yes, please give the name of the Adult Carer* Email Adult Carer Adult Carer's Phone No:*What areas does the carer support the Person(s) Being Cared For:* Domestic Tasks Personal Care Emotional Support Practical Support Other If Other, please give details* Please summarise how the carer is impacted by their caring role, what you hope for the carer to gain from the service and any additional information regarding the family situationIs there a person(s) under the age of 18 involved in caring for the named Person(s) Being Cared For? Yes No Are there any young carers involved? If you wish to refer a young carer, please follow this linkName of Young Carer* First Last What areas does the young carer support the Person(s) Being Cared For:* Domestic Tasks Personal Care Emotional Support Practical Support Other If Other, please give details* Name of Young Carer #2 First Last What areas does the young carer #2 support the Person(s) Being Cared For: Domestic Tasks Personal Care Emotional Support Practical Support Other If Other, please give details Name of Young Carer #3 First Last What areas does the young carer #3 support the Person(s) Being Cared For: Domestic Tasks Personal Care Emotional Support Practical Support Other If Other, please give details Name of Young Carer #4 First Last What areas does the young carer #4 support the Person(s) Being Cared For: Domestic Tasks Personal Care Emotional Support Practical Support Other If Other, please give details Barnet Carers Partners Forum The forum has been created with the collective aim being to better support the carers across Barnet. By inviting organisations who may be in regular contact with carers and bring their individual area of expertise to share their views on a regular basis, it is our aim that carers can access specific support between organisations. If you are interested in representing your organisation, please indicate below. I would like to be contacted regarding the Barnet Carers Partners Forum* Yes No Next Steps On submission of your referral, you will be emailed a PDF copy for your records. A member of the Adult Carers Team will be in touch with the carer to complete our registration form and carers assessment. We will make 3 attempts to contact the carer to complete these forms. In the event we are unable to get in touch with the carer, we may seek your assistance in making the carer aware of our communication attempts. Referrers can re-refer after closure.
